Virtual opioid poisoning education and naloxone distribution programs: A scoping review

The global opioid poisoning crisis is a complex issue with far-reaching public health implications. Opioid Poisoning Education and Naloxone Distribution (OPEND) programs aim to reduce stigma and promote harm reduction strategies, enhancing participants’ ability to apply life-saving interventions, including naloxone administration and cardiopulmonary resuscitation (CPR) to opioid poisoning. While virtual OPEND programs have shown promise in improving knowledge about opioid poisoning response, their implementation and evaluation have been limited. The COVID-19 pandemic has sparked renewed interest in virtual health services, including OPEND programs. Our study reviews the literature on fully virtual OPEND programs worldwide. We analyzed 7,722 articles, 30 of which met our inclusion criteria. We extracted and synthesized information about the interventions’ type, content, duration, the scales used, and key findings. Our search shows a diversity of interventions being implemented, with different study designs, duration, outcomes, scales, and different time points for measurement, all of which hinder a meaningful analysis of interventions’ effectiveness. Despite this, virtual OPEND programs appear effective in increasing knowledge, confidence, and preparedness to respond to opioid poisoning while improving stigma regarding people who use opioids. This effect appears to be true in a wide variety of populations but is significantly relevant when focused on laypersons. Despite increasing efforts, access remains an issue, with most interventions addressing White people in urban areas. Our findings offer valuable insights for the design, implementation, and evaluation of future virtual OPEND programs.


Introduction
The opioid poisoning crisis is a global health challenge with high fatality rates [1][2][3].The highest rates of opioid poisoning fatalities are seen in the United States, followed by Estonia, Canada, and Lithuania [2].Opioid-related fatalities have been exacerbated by the increasingly toxic and unregulated drug supply market, contaminated by fentanyl and other substances such as benzodiazepines [2,4,5].Beyond fatal opioid poisonings, the majority of opioid poisonings are non-fatal and contribute to the social, health, and economic costs of the global opioid poisoning epidemic [6][7][8].Opioid-related harms can affect people in all communities, ages, and socioeconomic groups, including family members, friends, healthcare professionals, and community members of people with lived or living experience (PWLLE) of opioid use [9,10].
Opioid Poisoning Education and Naloxone Distribution (OPEND) programs are strategies to train and equip people to provide life-saving interventions, including naloxone administration, to potential opioid poisoning events [11][12][13][14].While existing evidence demonstrates that OPEND can save lives, improve knowledge about opioid poisoning response, improve attitudes, and reduce stigma toward people who use substances, a significant research gap exists [11][12][13][14][15][16].Specifically, OPEND programs have predominantly been focused on in-person interventions, which may inequitably inhibit access for those who are unable or unwilling to access in-person services, including rural and remote populations [13,14,17,18].The COVID-19 pandemic prompted a shift away from in-person offerings, increasing interest in the implementation and evaluation of virtual OPEND programming [19,20].However, there are no current knowledge syntheses on virtual OPEND programs.
Therefore, this scoping review reports on the existing literature on opioid poisoning education conducted entirely without in-person interaction.In compiling a cohesive overview of existing virtual OPEND programs and their outcomes reported in the literature, our goal is to support the development and evaluation of future programs.

Objective and review question
We synthesized the literature on virtual OPEND programming.We structured our scoping review question based on the Participants, Concept, Context framework for scoping reviews [21], as follows: • Participants: People at risk of opioid poisoning, likely to witness opioid poisoning, or otherwise interested in OPEND program participation.
• Concept: Any opioid poisoning education program conducted entirely at a distance, without in-person interaction between participants and staff.

Language and terminology
Although 'overdose' is a more common term, we use the term 'poisoning' throughout this paper.The word 'overdose' suggests that the primary cause of the health emergency is an incorrect dose, which most of the time is not necessarily the case and can place stigmatizing blame on people who experience opioid poisoning.Therefore, we suggest using the term 'poisoning', which can shift the attention to the broader social context leading to these emergencies, such as the unregulated drug supply.We also prefer and refer here to the term 'opioid poisoning education and naloxone distribution' (OPEND) over 'take-home naloxone' because the latter does not fully acknowledge the circumstances of the many unhoused people and the educational and non-pharmacological elements that are essential to these programs.

Approach and protocol
The design and methods for this review are reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) [22].Further guidance was gained from an adapted version of Arksey and O'Malley's methodological framework on scoping reviews and the Joanna Briggs Institute methodological guidance for conducting scoping reviews [23,24].A preliminary search of MEDLINE and the Cochrane Database of Systematic Reviews was conducted, and no current or ongoing literature reviews on the topic were identified.We developed a scoping review protocol and registered it on Open Science Framework [https://doi.org/10.17605/OSF.IO/EW9RQ] [25].

Search strategy
An initial search was undertaken on MEDLINE to identify papers on the topic using terms such as 'virtual', 'education', 'opioids', and related terminology [21].The text words contained in the titles and abstracts of relevant papers and index terms were used to develop a full search strategy for OVID MEDLINE, OVID Embase, EBSCO CINAHL, OVID PsycINFO, The Cochrane Library, SCOPUS, and ERIC (S2

Source of evidence selection
Following deduplication in Covidence, titles and abstracts were screened independently by four reviewers (BDS, RFN, AK, and AMS) based on the inclusion criteria.The full-text review of selected studies was undertaken by BDS and RFN.Reasons for exclusion during the full-text review were recorded following PRISMA guidelines (Fig 1) [22].Disagreements between the reviewers at any stage of the selection process were resolved through discussion until a consensus was reached.

Data extraction
Data were extracted in Covidence from included articles by two independent reviewers (BDS and RFN) using a data extraction tool modified from the JBI Manual for Evidence Synthesis [26].The data extraction tool was first piloted with five papers per reviewer and modified as necessary.The data extracted included publication details (year of publication, country, and type of study), information about the target population (demographics such as age, gender, and race/ethnicity), intervention components (e.g.videos, telephone calls), topics addressed by the intervention, key findings, and other details relevant to the review question.All variables extracted are provided (S3 Table ).Disagreements between the reviewers were resolved through discussion until a consensus was reached.

Data synthesis
The extracted data are synthesized and summarized in narrative and tabular format.In conducting our analysis, we categorized training into major topic areas, including prevention, response, laws and law enforcement, and developed subtopics to identify the most reported topics addressed in opioid poisoning and naloxone administration training.This analysis was conducted by examining the content of training materials reported in the relevant publication, its citations, or when possible, through a direct review of original educational resources.

Results
After deduplication, 7,722 out of the initial 10,003 papers were identified for further review.
After title and abstract screening, 7,631 papers were excluded, and 91 were reviewed in full text (Fig 1 ).A full-text review elicited 31 papers for inclusion within this scoping review.Sisson et al., 2023 conducted a single study that was reported in two papers and was, therefore, reported here as a single study [27,28].The characteristics of the included papers, such as type of study, number and type of participants, sex or gender, and age, are specified in Table 1.Of the papers included in our analysis, 29 (97%) were conducted in the United States of America and one in Australia [29].
Fourteen studies (47%) reported mean participant ages.Participant ages ranged from 11 to 69 years, with the majority falling between 25 and 64 years.There was notable variation in participation based on biological sex, with thirteen studies of 21 (62%) primarily including female participants and nine (43%) male participants.Most studies (70%, n = 21) reported biological • Significant increase in knowledge, not maintained at the 3-month follow-up.
• Increased participants' confidence in carrying out their duties.
• Videos got an average rating of 4.9 out of 5.
(Continued ) • Most respondents would recommend the website.
• Most participants visited the website for professional reasons.
• The most accessed pages were 'Resources and information', 'Signs of poisoning and how to respond', 'Team and thanks', and 'Personal stories', with the latter reported as the most helpful section.
• Addressing stigma and increasing awareness of naloxone were two primary themes recognized from participants' comments.• None of the participants had experience administering or carrying naloxone before the training.
• 12% of participants reported carrying naloxone in a 3-week follow-up, and one administered it.
• There were no significant changes in knowledge in both groups.
• There was an overall significant decrease in attitude scores.
• No difference between groups regarding knowledge and attitudes towards opioid poisoning response.
(Continued ) • Only one participant reported ever administering or carrying naloxone before the training.
• VR participants significantly improved their attitudes.
• Videoconference participants significantly improved their attitudes and knowledge of poisoning response.
• No significant differences between modalities.• 42% of participants in the education-only group obtained a naloxone kit, mainly the nasal spray.
• 16 participants reported using their naloxone over the 3-month follow-up period.
• No difference in naloxone utilization between groups.
• Most kits were used on friends or family members.
• All opioid poisoning reversals resulted in survival.

Available at rb.gy/ 60j32
Asynchronous video: • Increased knowledge of how to recognize and respond to opioid poisoning.
• Increased confidence in recognizing and responding to opioid poisoning.
• Almost all participants were highly satisfied with the content and methods.
(Continued ) sex rather than gender, with 10 of these presenting only male and female options.Four studies (13%) allowed participants to report their gender, while six (20%) did not provide sex or gender information.Data on race or ethnicity were not reported in thirteen (43%) of the studies.Among the studies reporting race/ethnicity, all of them had White or Caucasian participants as the majority [27,30,31,35,[37][38][39][40]42,45,[47][48][49][55][56][57][58].Specific racial identities were reported in a few studies, with Beiting  No papers provided information on participants' socioeconomic status.However, Huhn et al., 2018 reported that the median household income of participants was US$52,500, while Sisson 2023a reported between US$10,000 and US$49,000.Six studies (20%) provided data on participants' educational level, with 3 having most participants with a high school degree [27,32,58], 2 with the majority having a college degree [38,54], and two having most with at least a graduate degree [36,42].The geographical area in which participants resided was mentioned in six studies (20%).In four studies, most participants were from urban areas [33,39,40,42], while two studies specifically focused on rural regions [34,54].

Intervention approaches
Several strategies were employed for conducting virtual OPEND.A summary of intervention approaches is specified in Table 1, including the type of approach, duration, scales used to measure outcomes and key findings.A substantial number of the included studies (87%, n = 26) delivered their intervention over the internet, including videos (n = 9, with 2 virtual reality simulations), videoconferences (n = 6), courses (n = 5), slide presentations (n = 3), and websites (n = 3).Of the internet-based interventions, four additionally provided naloxone by mail.There were four telephone-based interventions (13%) coupled with mail-delivered naloxone.
Among the 22 studies that reported on duration, interventions ranged from 5 minutes to 2 hours, with most lasting approximately 20 minutes (n = 5, 17%).In four studies (13%), participants could complete the intervention in their own time [29,34,36,50].Of these self-directed interventions [29,34,36,50], one reported the average time taken for participants to complete their training [36], while none reported drop-out rates.
The 30 studies analyzed in this review incorporated a variety of topics into their interventions.The predominant theme was how to respond to, recognize, and prevent opioid poisoning emergencies.Some commonly mentioned steps were naloxone administration and calling 911.Additional topics included history and statistics on opioid poisoning, laws and law enforcement, specifics on naloxone use, and stigma.An overview of the educational components can be seen in Table 2.
Most studies utilized a pre-post design or post-training questionnaires.67% (n = 20) assessed participants' knowledge of opioid poisoning response, followed by 11 (37%) that gathered qualitative feedback and measured satisfaction rates.Ten studies (33%) focused on attitudes, behaviour, and stigma related to opioid poisoning emergencies, and another 10 tracked naloxone kit distribution, prescriptions, and administration during or after the intervention.
Other outcomes included confidence in responding to opioid poisoning, comparisons between different modalities, accessibility, barriers to access naloxone, preparedness, familiarity with virtual learning, and opioid use.Regarding assessment tools, 33% (n = 10) of studies used the Opioid Overdose Knowledge Scale (OOKS) and the Opioid Overdose Attitudes Scale (OOAS).Most studies (n = 7) adapted the scales for their intervention, while 4 (13%) developed new assessment tools.The Brief Opioid Overdose Knowledge Questionnaire (BOOK) and the Medical Conditions Regard Scale (MCRS) were each used by two studies (7%).Other scales used were the New General Self-Efficacy Scale and the Naloxone-Related Risk Compensation Beliefs Scale.

Key findings
Findings from the included studies are summarized in Table 1.
Videos (n = 9).Knowledge and confidence.Most studies reported an increase in knowledge about opioids, opioid use disorder (OUD), and opioid poisoning, as well as an increase in confidence in managing opioid-related situations [27,30,35,41,54,58].While Adams et al. (2020) showed that the knowledge increase was sustained for most participants at the 6-month follow-up, in Cerles et al. (2021) this increase was not sustained at the 3-month follow-up.
Attitudes and stigma.There was an improvement in attitudes and a decrease in stigma around OUD and opioid poisoning in several studies [30,38,40,41].Giordano et al. (2020), however, reported a significant decrease in attitude scores.
Training satisfaction.Participants generally found the training easy and interesting, and were highly satisfied with the content and methods, giving the videos a high satisfaction rating [27,27,30,35,54].
Previous experience or training.Many participants had personal experience with substance use or had proximity to opioid poisoning [37,38].Most were not previously trained in naloxone administration or had personal experience administering or carrying naloxone [38][39][40][41].
Videoconferences (n = 7).Knowledge and confidence.Most studies reported an increase in knowledge about the opioid epidemic, opioid misuse, opioid poisoning risks, and naloxone [31,40,48,49].There was also an increase in confidence in recognizing poisoning and administering naloxone [31,42].However, Hohmann et al. (2022) found no difference in knowledge about naloxone and perceived barriers to its implementation.
Attitudes.Some studies reported improved attitudes toward naloxone use and distribution [40,49].However, Hohmann et al. (2022) found no difference in attitudes toward naloxone, illicit opioid use, or prescribed opioid misuse.
Training and satisfaction.Two papers reported that most participants are comfortable with a virtual format but prefer in-person training [31,49].
Reach and diversity.Mathias et al. ( 2023) reported reaching both urban and rural populations, and substantial racial/ethnic diversity.Notably, Jensen et al. (2019) found that fewer people with substance use disorder were reached in the videoconference compared to the in-person group.
Slide presentations (n = 3).Knowledge and confidence.Two studies reported increased knowledge and one increased confidence about opioid use and poisoning after the intervention [32,34,44].Bergeria et al. (2019) noted a small decrease in knowledge at the 30-day followup.
Attitudes and stigma.One study found that the training was effective in decreasing stigma around prescribing naloxone [34].Another reported fewer opioid poisoning-risk behaviours after the intervention [32].
Training and satisfaction.All studies reported high levels of satisfaction or acceptability for their interventions [32,34,44].
Websites (n = 3).Knowledge, confidence and awareness.One study reported increased knowledge and confidence in discussing opioid poisoning [29], and another showed that most participants, with either a professional or personal interest in the training, correctly identified basic signs of opioid poisoning and appropriate responses [50].
Acceptability.Acceptability rates for naloxone kits distribution ranged from 73% to 93% [43,51,55,57].Participants with a personal interest in the training were more likely to report being very likely to obtain naloxone [50].The most common reason participants did not accept naloxone was because they felt it was unnecessary [51].Castillo et al. (2022) reported an increase in nurses' motivation and intent to prescribe naloxone to patients taking long-term opioids.Similarly, Hohmann et al. (2022) found that 66% of participants felt comfortable providing naloxone to people who use illicit opioids compared to 91% who felt comfortable providing it to people with prescribed opioids.
Barriers.The most frequently reported barriers to obtaining naloxone were related to the COVID-19 pandemic, lack of knowledge on how to access it, inability to get a prescription, cost, lack of availability, transportation, and stigma [37,53].Despite perceived barriers not impacting the willingness to prescribe naloxone, the highest perceived barrier for nurses was time constraints [34].
Naloxone use and outcomes.Most or all opioid poisoning reversals resulted in survival, and the majority of kits were used on participants' friends or family members [28,52,56].Giordano et al. (2020) reported that, though they did not distribute naloxone kits, 12% of participants reported carrying naloxone in a 3-week follow-up, and one administered it.Sisson et al. (2023b) reported that 42% of individuals in the groups without naloxone distribution obtained their kit.
Comparison between different modalities.Comparison groups.Four studies had a control group involving in-person training [33,41,45,49], and one study had a hybrid group [39].Other comparison groups included reading-only or course, slide or slide + quiz, and virtual reality video or videoconference.
Differences between formats.Three studies with an in-person or hybrid group showed no significant differences in preparedness, attitudes, satisfaction, and stigma scores between formats [33,39,41], and one reported greater knowledge in the in-person group [49].One study reported a significantly higher number of naloxone prescriptions obtained by participants in the virtual group [45].For papers with other comparison groups, there were also no significant differences between groups [32,40,46].Huhn et al. (2018) reported that the presentation-only group was more likely to complete the intervention compared to the group with the presentation coupled with a quiz [44].Sisson et al. (2023a) reported higher satisfaction in the naloxone distribution group compared to the group without naloxone distribution [58].Hohmann et al. (2022) showed an increase in the number of naloxone prescriptions obtained by participants only in the intervention group, but there was no difference related to other outcomes [42].

Discussion
This scoping review identified that there is considerable research and innovation underway in the implementation and evaluation of virtual OPEND, particularly since the start of the COVID-19 pandemic.Although this review did not include a critical appraisal, it is crucial to note that the diverse study designs, varying intervention durations, and different measurement time points complicate the analysis of intervention effectiveness.
Despite current challenges in analyzing intervention effectiveness, it is important to highlight the positive outcomes reported.Overall, virtual OPEND appears to be acceptable to participants and effective in increasing knowledge on how to respond to opioid poisoning, as well as improving attitudes and decreasing stigma about people who use opioids.Especially when coupled with naloxone distribution, programs appear to impact the motivation and willingness of people to respond to these emergencies.Notably, some studies demonstrated a high rate of successful resuscitations and decreased poisoning death rates [27,28,52,56].Therefore, while the diverse study designs present analytical challenges, they do not detract from the potential life-saving impact of virtual OPEND.
Our synthesis indicates that most interventions are primarily targeted at PWLLE of opioid use and potential bystanders, defined as individuals who could potentially witness opioid poisoning.A cross-sectional internet-based survey and a mixed-methods study have demonstrated the unique position of bystanders in reversing opioid poisonings and saving lives when they are equipped with naloxone and the knowledge to administer it effectively [59,60].
The bulk of these studies are based in the USA, with only one study conducted in Australia [29].However, opioid poisoning is a global concern, which demonstrates a pressing need to implement and evaluate virtual OPEND programs worldwide [2,13].Most studies had a prepost design, followed by descriptive studies, RCTs, and one non-randomized controlled trial, and did not include longitudinal data.Therefore, there is a need for more randomized and controlled trials that also assess the attrition of knowledge and the potential need or importance of retraining so more effective interventions can be designed and implemented in the future.
In addition, only 42% of studies utilized validated scales to measure outcomes related to opioid poisoning, with 62% of these studies using a modified version of the validated scales.These validated scales, especially OOKS and OOAS, were originally designed to assess illicit opioid poisoning risk factors and do not include knowledge specifically about naloxone [61,62].Therefore, there is a critical demand for updated and validated survey instruments to effectively evaluate these interventions [61,62].
Few studies reported sociodemographic variables and focused on the inclusion of historically marginalized populations.Yet, those more likely to be impacted by the opioid poisoning crisis include people living in rural and remote areas, individuals experiencing homelessness, those living in poverty, incarcerated individuals, and Black, Indigenous, and People of Colour [63].Without sociodemographic information, it is unknown whether sampling and selection biases and issues with representativeness have occurred, limiting the effectiveness of these interventions in addressing health inequities [64].
Moreover, most interventions did not make their training materials publicly available, and some of them did not report the educational content included in the intervention, hindering the potential for public dissemination and research replication.Among the studies that reported the content of their training, stigma reduction and policies on witness protection and naloxone use permission for opioid poisoning reversal were frequently not addressed, which if included, could have bolstered the outcomes [65,66].This is the first scoping review on fully virtual OPEND interventions, highlighting the outcomes and potential impacts of these programs.Other reviews have explored opioid poisoning interventions and their effectiveness but did not focus on virtual programming.Pellegrino et al., (2021) conducted a scoping review on first aid educational interventions for opioid poisoning published until 2019, showing the potential of these programs with most studies showing improved educational and clinical outcomes, despite the sparsity and lack of quality of the studies reviewed [14].Razaghizad et al. (2021) conducted an umbrella review on OPEND, demonstrating that there is credible evidence that opioid poisoning education programs improve knowledge and attitudes about opioid poisoning, enable participants to use naloxone safely and effectively, and reduce opioid-related mortality [13].Additionally, Tas et al. (2022) reviewed technological interventions that prevent, detect, or respond to opioid poisoning emergencies, with promising approaches that were still under development, such as smartphone apps for alerting and recruiting first aid volunteers to act on nearby opioid poisoning events [67].
Our findings suggest the potential effectiveness of virtual OPEND interventions as a lifesaving tool, and can assist researchers and public health practitioners in designing, implementing, and evaluating future OPEND programming.We recommend providing more funding, personnel, and technology to amplify the implementation and evaluation of these programs.We believe coupling first-aid opioid poisoning training with a well-structured naloxone distribution system can notably increase the positive outcomes of this intervention.To address inequities and specific local challenges, we recommend sociodemographic information to be collected and interventions to be tailored by working closely with local communities and governments.It is also crucial to invest in the development or update and validation of relevant evaluation tools that can better assess OPEND's effectiveness for diverse outcomes and in diverse settings.Additionally, we suggest conducting longitudinal studies to address the longterm outcomes of these interventions, including the duration of knowledge and the necessity for retraining.

Limitations
Our review has limitations.One such limitation is the lack of extensive and evidence-informed critical appraisal of the studies included.For this reason, it is not possible to indicate the quality of the studies or extract a meaningful conclusion.In the context of diverse study designs, different methodologies, intervention durations, and measurement time points can introduce variability that makes it challenging to compare results across studies.The variability of the studies makes it unclear whether the results synthesized in our review can be extrapolated to other settings, study designs or populations.Despite our best efforts to design a comprehensive search strategy without imposing any limitations, the constant updates and rapid publication of new research on technology-based interventions may result in the unintentional omission of important studies by the time of publication.We also acknowledge that many impactful programs addressing the opioid poisoning crisis are currently available online but did not involve a research design or share publicly available data on outcomes of these interventions and, therefore were not suitable for this review.Additionally, the lack of detailed information about the interventions in many studies may have impacted the accuracy of our synthesis, as we did not reach out to the authors for additional information.

Conclusion
This review synthesizes the literature on virtual Opioid Poisoning Education and Naloxone Distribution (OPEND) programs, and underscores gaps in program implementation and evaluation.Currently, it is difficult to draw substantial conclusions on OPEND effectiveness due to the variety of study designs and the lack of updated and validated evaluation methods.However, existing evidence points to the potential to increase knowledge, decrease stigma, and ultimately reduce morbidity and mortality due to opioid-related harms, which enhances its potential as a life-saving tool.This life-saving knowledge can have substantial and positive impacts on populations who are not currently being adequately reached by in-person OPEND interventions.

Fig 1 .
Fig 1. PRISMA flowchart.This figure depicts papers that were included in the scoping review at each stage of the review process, according to PRISMA guidelines.https://doi.org/10.1371/journal.pdig.0000412.g001 et al. (2022) reporting only the percentage of Black individuals, while Yates et al. (2018) and Moses et al. (2021) reported only the percentage of White individuals.
Table).A University of Toronto health science librarian provided expertise in optimizing the search strategy.The search strategy, including all identified keywords and index terms, was adapted for each included database.Searches were conducted on June 1, 2023, except for the grey literature search, which was conducted on July 27, 2023.The grey literature search included the Canadian Agency for Drugs and Technologies in Health (CADTH) Grey Matters website, the System for Information on Grey Literature in Europe (OpenGrey), and TRIP Pro.Additionally, we screened the references of included papers to identify additional ones (reference tracking), but no other papers were identified.All search strategies are documented in S2 Table.

Table 1 .
(Continued) • Reported barriers to obtaining naloxone included: not being sure how to obtain it, inability to get a prescription, lack of availability, and cost.

Table 1 .
(Continued) • Participants preferred the nasal formulation.This table shows the characteristics of the papers included in this scoping review.a All papers reported 'biological sex', except for Mathias 2023, Farrugia 2022, French 2021, and Yang 2021.b Opioid Use Disorder (OUD).c Brief Opioid Overdose Knowledge (BOOK).d Opioid Overdose Knowledge Scale(OOKS).e Opioid Overdose Attitudes Scale (OOAS).f Medical Condition Regard Scale (MCRS).g Naloxone-Related Risk Compensation Beliefs Scale (NaRRC-B).